Standards and Procedures for Adult Residential Facilities

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1 Standards and Procedures for Adult Residential Facilities Social Development 2012 REVISED: September 16, 2013

2 Revised:September13,2013

3 History of Modifications/Updates November 17, 2014 Appendix F Appendix F was removed Staff Ratio February 27, Staff Ratios + addition to Appendix J Changes to 5.7 Staff Ratios and addition of Appendix J.

4 TABLE OF CONTENTS SECTION 1: INTRODUCTION 1.1 Overview 1.2 Definitions 1.3 Mission of Social Development SECTION 2: ADMINISTRATION 2.1 Ownership and Responsibility 2.2 Organization Chart 2.3 Mission Statement 2.4 Goals and Objectives 2.5 Policies and Procedures 2.6 Compliance with Laws and Regulations 2.7 Application Process 2.8 Approval Process 2.9 Financial Management 2.10 Insurance 2.11 Reporting an Incident 2.12 Reporting a Death 2.13 Reporting a Missing Resident 2.14 Discharge or Temporary Absence of a Resident 2.15 Revoking of a Certificate of Approval 2.16 Closure of a Residential Facility by the Operator 2.17 Sale of a Facility 2.18 Relocation of a Facility

5 2.19 Move between Regions 2.20 Quality of Services 2.21 Concerns of Residents SECTION 3: PERSONNEL 3.1 Employment Criteria for all Staff Members 3.2 Files 3.3 Staff Development 3.4 Performance Appraisal SECTION 4: ENVIRONMENT AND SECURITY 4.1 Bedrooms 4.2 Bathroom 4.3 Kitchen/Dining Room 4.4 Hallways/Stairways 4.5 Exits 4.6 Recreation/Common Living Area 4.7 Renovations 4.8 Heating 4.9 Sprinkler System 4.10 Fire Prevention 4.11 Fire Safety Requirements where Residents are Non-ambulatory 4.12 General Health Standards 4.13 First Aid 4.14 Installation of Lifts and Elevators in Adult Residential Facilities 4.15 Emergency Preparedness

6 SECTION 5: RESIDENT CARE 5.1 Client Profile and Service Types 5.2 Admission 5.3 Individualized Service Plan 5.4 Elements of Programming 5.5 Behaviour Management 5.6 Use of Restraining Device 5.7 Staff Ratios 5.8 Nutrition Services 5.9 Personal Care 5.10 Do Not Resuscitate Order 5.11 Medical Consent 5.12 Hospital Transfers 5.13 Administration of Medication 5.14 Communicable Disease 5.15 Special Services 5.16 Money Management 5.17 Clothing 5.18 Resident Records SECTION 6: SOCIAL ENVIRONMENT 6.1 Orientation upon Arrival and Departure 6.2 Resident Rights

7 SECTION 7: APPENDICES Appendix A: Forms Application Form for an Operator of an Adult Residential Facility (04/08) Reference Form (5/08) Resident Medical Report (6/08) Incident Report (5/08) Report of Death (5/08) Financial Record (5/08) Personal Record of Resident (5/08) Medication Record (5/08) Appendix B: Oath of Confidentiality Appendix C: Special Care Home Plan Review Appendix D: Use of Oxygen Appendix E: Admission of private-pay resident in a special care home Appendix F: Nutrition Appendix G: Foot Care Appendix H: Agreement of Trustee Form Appendix I: Hospital Transfer Information Appendix J: Staff Ratio

8 INTRODUCTION Overview The Standards and Procedures for Adult Residential Facilities provide detailed information to assist staff of Social Development, board members, operators and staff of Residential Facilities. Unless otherwise specified, the information contained in this document applies to all residential facilities offering long term care services under the Family Services Act. Users of this Document should insert new directives in the document on receipt maintain a master copy of the document review and update the document regularly submit comments and suggestions to the Adults with Disabilities and Seniors Services Unit 1.2 Definitions Activities of Daily Living (ADL) Ambulatory Non-ambulatory Care Refers to tasks related to personal care, for example, eating, dressing, grooming, indoor mobility, transfer, bathing, foot care and bowel and urinary management. Ambulatory refers to residents who are not bedridden. Ambulatory includes residents who use a wheelchair, a cane or require assistance of another person for transfers. Non-ambulatory refers to residents who require total assistance from another person for transfers and mobility. Refers to the provision of assistance with the Activities of Daily Living, Instrumental Activities of Daily Living and/or health related activities. Refers to activities where hands-on help is provided to assist the client with a task or perform the task for the client. Case Manager Refers to a government employee who works with the clients in partnership with the operators and significant others to develop and implement an individual service plan Page 1 of 5

9 INTRODUCTION 1 Community Placement Residential Facility Home Residence Residential Centre Transition House Coordinator Holistic Inclusion Regulation defines a Community Placement Residential Facility as a home, a residence or a residential centre. A Special Care Home, a Community Residence or a Transition House may be classified as any one of these types of facilities. Refers to A community placement facility providing care services to fewer than three (3) residents and in which one(1) or more of the residents are receiving special care assistance (financial assistance) Refers to A community placement facility that is designated by the Minister to be a community placement resource under 24 of the Act and provided care services to three (3) or more residents but fewer than ten (10) residents Refers to A community placement facility that is designated by the Minister to be a community placement resource under 24 of the Act and provides services to ten or more residents Refers to A community placement residential facility that is designated by the Minister to be a community placement resource under 24 of the Family Services Act and provides accommodations for thirty (30) days or less and support services to abused women and their children. Refers to an employee of Social Development whose responsibilities include recruiting Adult Residential Facilities as per need, assessing applications for approval to determine an operator s ability to meet criteria as stipulated under the Family Services Act and corresponding regulations and standards, recommending the issuance of the Certificate of Approval, monitoring compliance to the legislation and standards and conducting inspections. Refers to emphasizing the whole person by encompassing the physical, emotional, social, spiritual, and behavioural aspect of the individual. Refers to including residents in communities where they participate fully in community life Page 2 of 5

10 INTRODUCTION 1 Individual Service Plan Instrumental Activities of Daily Living (IADL) Operator Primary Staff Member Resident Residential Facility Staff Member Sundowning Supervision Refers to a written, time limited and goal oriented statement. This statement sets out the specific means for matching program activities with particular needs, abilities and circumstances of residents. Refers to tasks that complement well being, for example, using a telephone, shopping, meal preparation, house cleaning, money management, laundry and outdoor mobility. Refers to a person who by himself/herself or through his/her agent operates a community placement resource. The operator is the owner of the business and his/her name appears on the Certificate of Approval. For a non-profit organization, the name of the organization appears on the Certificate of Approval. Refers to an operator or a person employed in a residential facility who spends seventy five percent (75%) or more of their time at a residential facility providing for the direct care of residents. Refers to a person who resides in a Residential Facility. Residents are nineteen (19) years of age or older and require care/supervision. Refers to an approved facility providing care and supervision to adult residents. Refers to a person who is employed to work in a residential facility and includes an operator who is a primary staff member and a volunteer. The term sundowning refers to people who become increasingly confused at the end of the day and into the night. Sundowning isn t a disease, but a symptom that often occurs in people with dementia, such as Alzheimer s disease Refers to the overseeing of the safety or well being of a person. Supervision involves the presence or availability of a person or equipment. Refers to activities, for example, monitoring, teaching, Page 3 of 5

11 INTRODUCTION 1 counselling, cuing and guiding. As well, refers to the use of equipment, for example, a medical alert device or cardiac monitor. Volunteer According to Regulation of the Family Services Act, two volunteers may constitute one (1) primary staff member where each volunteer provides more than ten hours of service per week to a residence or a residential centre; and each volunteer provides seventy-five per cent or more of his time of work at a residence or a residential centre providing direct care to the residents. Well Being Refers to the optimal degree of social, mental, and physical health attainable for each individual. 1.3 Mission of Social Development The mission of Social Development is to work with clients in achieving self reliance, an improved quality of life and protection for those who need it. Social Development provide programs and services as determined by the assessed needs of individuals. The following principles reflect this approach. Informal Care Giving Client Focused Informal care giving must be sustained to complement the formal system. This principle recognizes the important role that family members, friends, neighbours and volunteers perform in providing assistance to individuals requiring long term care. In a client focused approach, the dignity of the individual must be recognized and respected. Social Development views the concept of community inclusion as an important factor in the planning and delivery of long term residential services. Long term residential services are provided in the environment that can most effectively and efficiently meet an individual's assessed needs. Quality Assurance Long term care residential services are monitored regularly. The purpose of this monitoring is to enhance Page 4 of 5

12 INTRODUCTION 1 accountability, effectiveness and efficiency in the planning and delivery of these services Page 5 of 5

13 ADMINISTRATION Ownership and Responsibility The operators must ensure that the ownership of the Adult Residential Facility operation is identifiable and must provide proof of ownership to the Adult Residential Facility Coordinator on request have the ultimate responsibility and accountability for the efficient and effective management of the facility display their Certificate of Approval to operate an Adult Residential Facility in a common area. have all staff sign an agreement to protect the confidentiality of all personal information of the resident. Refer to Appendix B 2.2 Organization Chart Operators must develop and display a written and dated organizational chart. This chart must describe the current relationships, responsibilities, lines of authority and the lines of communications within the facility. 2.3 Mission Statement Operators must ensure that a written Mission Statement is developed that describes the intention of the operator to provide holistic care to the residents of their facility provides guiding principles for the facility which are consistent with the principles of the Long Term Care Strategy is reviewed on a regular basis to assess its continuing suitability communicates its mission to the staff, residents, families, and significant others is displayed in a common area in the facility 2.4 Goals and Objectives The operator must develop written goals and objectives that provide for the medical, physical, spiritual, social and psychological support that meet the needs of the residents. The goals and objectives must be consistent with the Mission Statement and form the basis for planning, operating, reviewing and revising programs and services. Page of 10

14 ADMINISTRATION Policies and Procedures The operator must develop written policies and procedures to ensure security and development of the residents. These policies and procedures may include but are not limited to administration personnel environment and security social environment resident care Policies and procedures must be documented to enable staff to carry out the operations of the facility communicated and accessible to the staff reviewed at regular intervals with revisions communicated to the staff Helpful Information Written policies and procedures give guidance to staff and promote consistency in application. To accomplish this consistency, document policies and procedures in sufficient detail to enable staff to carry out the operations of the facility in a safe and consistent manner. 2.6 Compliance with Laws and Regulations Operators must comply with Federal, Provincial and Municipal laws and regulations relevant to the facilities they operate. They include but are not limited to Part II of the Family Services Act and Regulation Health Act Fire Prevention Act Family Income Security Act and Regulations Infirm Person's Act Mental Health Act Employment Standards Act Occupational Health and Safety Act and Regulation The Human Rights Act Smoke Free Place Act Page 2 of 10

15 ADMINISTRATION 2 Copies of all legislation are available at most public libraries, the Queen s Printer or on the Internet. Refer to 2.7 Application Process To be considered for approval to operate an Adult Residential Facility applicants should contact the Adult Residential Facility Coordinator. Depending on the special care home vacancy rate in the area, the application may not be processed at the time it is received. To be considered for approval to operate a Specialized Care Bed Home, an applicant must first submit a proposal through a Request for Proposal (RFP) issued by the Department of Government Services. The RFP process applies only to new Specialized Care Bed. Social Development cannot guarantee occupancy levels in Residential Facilities. A new Special Care Home approved after May 1, 2009 must provide special care home services in a separate stand alone building; the number of residents shall not exceed the number indicated on the approval; and the number of residents indicated on the approval shall not exceed 60 not exceed two stories in height as defined by the NBC. Specialized Care Bed Homes must have services offered on one floor (for new facilities) have a courtyard attached to the facility, accessible and fenced in not exceed 18 residents not have a mix of level 2 and level 3 residents, except for facilities in the process of converting their clientele by admitting only residents with specialized care needs have a physical layout designed for clients with memory disorder (for new facilities) In Addition, Specialized Care Bed Homes must be one of the following: a separate, stand-alone facilities, or a "distinct operations" in a multi-purpose facility. Living accommodations for specific clienteles are located on separate floors or in separate wings or units. Accommodations for meals could be shared. Occasionally, residents can participate together in recreational activities, or Page 3 of 10

16 ADMINISTRATION 2 a special care home conversion by attrition (from existing level 1 and 2 beds to Specialized Care Beds). For existing homes who wish to convert and who meet the conditions of approval, there will be a freeze on level 1 or 2 admissions until such time as the conversion is complete. Submit the following documents to the Adult Residential Facility Coordinator to operate a facility completed Application Form for an Operator of an Adult Residential Facility # (04/08), including a curriculum vitae valid First Aid/CPR Certificate and other certificates showing qualifications for the applicant and each prospective staff Social Development Record Check and Criminal Record Check Consent forms for the operator and each prospective staff inclusive of volunteers inspection report from the District Medical Health Office for facilities of three (3) or more beds inspection report for facilities of four (4) or more beds from the Office of the Fire Marshal letter from the Office of the Fire Marshal, indicating that the Special Care Review Plan has been reviewed. Refer to Adult Residential Facilities Plan Review, Appendix C where applicable, a letter from municipal officials, stating that the location of the facility is in accordance with zoning by-laws where applicable, an inspection report from the Department of Public Safety, showing that lifts and elevators were inspected approval, or renewal of an approval, to operate a residential facility is subject to a fee based on the number of beds. The licensing fee covers the cost of the approval process. Fees are not refundable the fee for an approval or the renewal of an approval is home with less than three (3) beds, $25.00 residence with three to nine (3-9) beds, $45.00 residential centre with ten (10) or more beds, $65.00 Residential facility standards and procedures must be met prior to approval of the facility. Annually, the Adult Residential Facility Coordinator will send to operator the Application Form for an Operator of an Adult Residential Facility # (4/08) ninety (90) days prior to the expiry date of the Approval. The Operator will return the application form to the Adult Residential Facility Coordinator within sixty (60) days, include the corresponding fee and other information in accordance with the application form Page 4 of 10

17 ADMINISTRATION Approval Process Anyone wishing to operate a Residential Facility must be cleared through the Social Development Record Check and the Criminal Record Check. Operators, staff and volunteers have to undergo a Social Development Record Check at minimum every five (5) years and when there is reason to believe that an individual has been involved with the Department in accordance with 1.2 of the Social Development Record Check and Criminal Record Check Policy. If the Social Development Check indicates no contravention, the Criminal Record Check can be initiated. The Criminal Record Check must be undertaken, at minimum every five (5) years and when there is reason to believe that an individual has been convicted of a criminal offence. For existing operators who are seeking approval for a new Specialized Care Bed Home, the following applies: The ARF Coordinator confirms that the operators are able to provide quality services to residents in compliance with legislative and standards requirements. Inspection reports of existing facilities will be reviewed as part of the approval process. Operators with a history of substantiated complaints/incidents and/or noncompliance with Standards and Regulations may not be considered for approval. Operators of facilities undergoing active investigations, or where allegations of abuse or neglect have been substantiated, will not be considered for approval. 2.9 Financial Management Operators must be responsible for the management of financial resources and safeguarding of monies entrusted to the facility administer an internal financial system that is compatible with the financial reporting requirements of Social Development Helpful Information Social Development may request reports and/or supporting documentation to monitor adherence to legislation, policy and standard Page 5 of 10

18 ADMINISTRATION 2 collect from the client the amount of financial resources indicated on the notification of financial subsidy, consistent with Social Development Standard Family Contribution advise the Case Manager of any changes in financial status that may affect contributions to services by a subsidized client 2.10 Insurance Operators should carry insurance to cover property damage. Social Development is only responsible for damage done to a facility by a resident when the resident is under the legal care of the Minister, that is, court ordered. Operators must have an insurance policy covering proof of a minimum one million dollar ($1,000,000) liability to cover residents for any accident, mishap or other incidents on the premises liabilities to residents who are passengers in any vehicle owned by the operators. Employees using their own vehicle to transport residents must show proof of a minimum of one million dollars ($1,000,000) liability coverage proof of a minimum of one million dollars ($1,000,000) liability to cover residents arising from any accident, mishap or other incidents incurred while on an outing either in the company of operators or their designates Sometimes residents living in Adult Residential Facilities participate in external activities. These activities must follow safety rules approved by current laws or regulations and in accordance with the existing staff ratio Reporting an Incident Operators must report any incident involving residents to their next-of-kin or legal representative, their Case Manager and the Coordinator. Operator or his designate reports the following incident immediately, and an Incident Report ( (5/08)) must be sent to the Case Manager with a copy to the ARF Coordinator within 24 hours Suspected physical abuse, sexual abuse, mental cruelty or neglect Missing resident (elopement/wandered) Disasters *Suspicious death Suicide Attempted suicide *Suspicious death is a death that is sudden and unexpected and is from any Page 6 of 10

19 ADMINISTRATION 2 cause other than disease or natural causes. For the following incidents, an Incident Report must be sent to the Case Manager by the Operator, or his designate, with a copy to the ARF Coordinator within 24 hours Injury/illness requiring medical attention Behavior necessitating the use of physical restraints Medication mismanagement Admission to hospital Falls Incident involving conduit and attitude Operators must place a copy of the incident report in the file of the resident affected provide a copy of the incident report to the client on request 2.12 Reporting a Death Operators must notify immediately police, if the death is suspicious or untimely physician or 911, when the death occurs on the premises next-of-kin or legal representative Extra Mural Program, if the resident is a client Case Manager and the Adult Residential Facility Coordinator Operators must forward a Report of Death Form # (5/08) to the Adult Residential Facility Coordinator within forty-eight (48) hours of the death of the resident whether the resident died at home or in hospital Reporting a Missing Resident Operators must immediately report all absences without notification to the local police, the Case Manager or the Coordinator, and the next of kin/contact person, if the safety of the resident is in jeopardy report within six (6) hours, if the safety of the resident not deemed to be in jeopardy. Helpful Information After regular working hours, operators can report the absence of residents by Page 7 of 10

20 ADMINISTRATION 2 calling the local office of Social Development at Discharge or Temporary Absence of a Resident On discharge of a resident, operators must ensure that the resident, the next of kin, the coordinator and case manager are notified at least fifteen (15) days prior to the date of discharge. Operators may discharge a resident anytime the resident is a safety threat to themselves or other individuals in the facility Personal Record of Resident Form # (5/08) is forwarded to Social Development Resident's Financial Record Form # (5/08) and Medication Record Form # (0/08) are forwarded to the new operator personal monies of residents are transferred to the appropriate person, for example, resident, case manager, new operator, or family member residents take all of their belongings and medication When a resident leaves a residential facility on a temporary basis, Social Development continues to subsidize placement up to thirty (30) days, for example, to enter a medical or psychiatric facility, to visit family or friends. The LTC Supervisor may grant extensions for exceptional situations, that is, longer stay in hospitals with intent to return to the facility. During the temporary absence, clients continue to receive the comfort and clothing allowance Revoking of a Certificate of Approval Social Development may modify, revoke, or refuse to renew a certificate of approval if investigation confirms abuse and/or neglect of residents facility operates in contravention of the relevant Standards, Acts and Regulations and the operator refuses to commit to the necessary improvement 2.16 Closure of a Residential Facility by the Operator The operators must advise the Coordinator, the resident and the next-of-kin at least sixty (60) days prior to the closing date consult with the Case Manager regarding sensitive issues that may affect Page 8 of 10

21 ADMINISTRATION 2 notifying the resident 2.17 Sale of a Facility When selling a facility a Certificate of Approval is not transferable to a new operator operators must send written notice to the Adult Residential Facility Coordinator prospective buyers must complete the Application Form for an Operator of an Adult Residential Facility # (04/08), and meet all other requirements to operate a residential facility operators must send a written notice to the Adult Residential Facilities Coordinator once the sale is finalized following approval of the new operator, the Adult Residential Facility Coordinator must send a recommendation for licensing to the Supervisor of the Adult Residential Facility Coordinator If the sale of the building does not result in a new operator, a new application is not required. For example, the owner was not the operator 2.18 Relocation of a Facility A Certificate of Approval is only valid for a specific facility. If the operation moves to a new location, a new application is required. The new application must include a copy of the floor plan, fire and health inspections and proof of zoning compliance Move between Regions An operator may move to another region if the coordinator is consulted prior to the move residents and their families agree to the move residents move with the operator vacancy rate is respected new facility is inspected and approved new certificate is issued 2.20 Quality of Service Operators must ensure a sufficient quantity of services of high standard Concerns of Residents Operators should Page 9 of 10

22 ADMINISTRATION 2 establish and follow a regular written procedure for hearing concerns of residents explain to the residents the procedure for hearing their concerns in a clear and simple manner. Operators should indicate that residents can express concerns without fear of retribution make the procedure accessible to the residents and their relatives or advocates inform staff of written procedures for addressing concerns of residents, on initial hiring and at regular staff meetings record the concerns made by the residents in a daybook investigate concerns from residents or their relatives or advocates record the outcome of the investigation in the daybook Page 10 of 10

23 PERSONNEL Employment Criteria for all Staff Members Operators must ensure that all staff members have the required qualifications to work in facilities. This includes staff that provides direct care to the residents, cooks and housekeepers. Staff must have a valid standard Emergency First Aid and Cardio Pulmonary Resuscitation certificate. Certification must be renewed prior to expiry date comply with the terms of the Social Development Record Check and Criminal Record Check. be sixteen (16) years of age or over. Staff under nineteen (19) years of age must be supervised by an adult primary staff member at all times while providing care services directly to residents Candidates seeking employment in an adult residential facility must have taken one of the following training programs if they want to provide direct care to residents in Special Care Homes, Community Residences or Specialized Care Bed Homes. Home Support Worker Program, or Special Care Home Worker Program, or Health Care Aid Program, or Human Services Program, or Nursing Assistant Program The operator of a Specialized Care Bed Home, or at least one primary staff member, must be a registered nurse or a Licensed Practical Nurse (LPN). If not, the LTC Program Delivery Manager may exceptionally authorize the operator to purchase nursing services (minimum 1 hour per week per resident) from a registered nurse. Operators must try to fill positions with qualified employees at time of hiring. When the operator can show that attempts to recruit qualified employees have been unsuccessful, operators have up to one year to ensure all staff meet the required training. These staff must be under the supervision of qualified staff, unless an exemption by the Coordinator is granted. Staff should demonstrate, through a training plan, how they intend to meet the required qualifications. Casual or relief care workers must have as a minimum a grade 12 education. Page of 2

24 PERSONNEL Files For each employee, operators must maintain a personnel file that contains oath of confidentiality identifying information, for example, name, address, date of birth, social insurance number documentation of qualifications that include professional qualifications, valid standard Emergency First Aid and Cardio Pulmonary Resuscitation Certificate as well as a verification of current registration results of Social Development Record Check and Criminal Record Check orientation checklist performance appraisals 3.3 Staff Development The operator must encourage staff and any board members to take part in educational activities, for example, suicide prevention seminars, behaviour management, care requirements for seniors with dementia, the principles of care, occupation health and safety, or any other program that may be beneficial to staff provide an orientation to new staff within two (2) weeks of hiring 3.4 Performance Appraisal Operators must appraise the job performance of each employee in writing. This appraisal process must be conducted prior to the end of the probationary period, and at least annually thereafter be documented with the date and signature of both the employee and operator have the original document placed on the personnel file of the employee who receives a copy Performance appraisals of employees who are immediate family members of the operators are not required. Page of 2

25 ENVIRONMENT AND SECURITY Bedrooms Measurements A basement room where the floor is more than 120 centimetres (4 feet) below ground level must not be used as a bedroom for a resident. Bedrooms in basements cannot be used in facilities approved after May 1 st, 2009 if there is no access to the basement at ground level. Bedroom measurements must provide a ceiling height of at least 2.13 metres (7 feet) over half the required floor area. Heights less than 1.37 metres (4.5 feet) are not included in the floor area. have at least 9.2 square metres (100 square feet) per person for single occupancy or 6.7 square metres (72 square feet.) per person for double occupancy. Double occupancy should only be used when requested by the client. Private bathrooms are not included in the floor area. allow space of at least 0.56 square metres (6 square feet.) for personal possessions and decorations. Windows Each bedroom must have a glass area of at least five percent of the wall area at least one window a minimum width of 60 centimetres (23.62 inches) and a minimum area of.55 square metres (5.92 square feet) For people in wheelchairs or the physically inactive, each window must have a sill height of at least sixty (60) centimetres (24 inches) and at most eighty (80) centimetres (32 inches) from the floor unobstructed view at a horizontal level from a sitting position Beds Beds must have space of at least one metre (39 inches) between them single bed that is a minimum of 1.91 metres (75 inches) in length and a minimum of 1 metres (39 inches) in width double bed that is a minimum of 1.37 metres (54 inches) in width comfortable mattress. Water beds are acceptable Page of 9

26 ENVIRONMENT AND SECURITY 4 pillow with pillow case, two sheets and two coverings at minimum clean bed linen as necessary, but at least once a week clean coverings as necessary, but at least every six months comfortable and waterproof sheets, when necessary Hospital Beds are acceptable only if required for a specific resident must be removed when that specified resident leaves must have a written rationale placed on the file of the specified resident, as kept by the Operator Furnishings Bedroom furnishings must include dresser bedside table and lamp mirror chair waste basket made of non combustible material other items indicated by Coordinator Privacy Operators must provide bedrooms that are self-contained with floor to ceiling walls and well fitting doors. Operators must not use folding doors do not access another room are separated by gender, unless residents request other arrangements accommodate no more than two persons 4.2 Bathroom Bathrooms must provide paper towel or client specific cloth towel liquid soap dispenser and tissue toilets and wash basins in a ratio of at least one (1) per three (3) residents at least one (1) bathtub for six (6) residents. Operators may substitute showers for bathtubs when safety permits and there must always be at least one (1) bathtub or a barrier free accessible shower non-slip material on the bottom of each bathtub and shower Page of 9

27 ENVIRONMENT AND SECURITY 4 ventilation with either a window or a fan door for each bathroom that locks to ensure privacy but opens from the outside in an emergency access on the same floor, where necessary access no more than one floor away for normal use grab bars conveniently located near the bathtub and toilet, if required by the residents 4.3 Kitchen/Dining Room Each kitchen must have refrigerator, stove and sink in good working condition storage for all foodstuffs, cleaning supplies and other housekeeping products utensils in good repair for cooking and eating. Operators must not provide disposable utensils for daily use For smaller homes, operators should Helpful Information furnish the dining area so that people involved with the facility can eat together in family style provide the same quality of tableware to residents as that used by the staff have the Case Manager or the ARF Coordinator approve all exceptions. 4.4 Hallways/Stairways Hallways must be unobstructed, well lighted, and at least 110 centimetres (43.33 inches) in width to allow proper circulation. Steps of stairwells must be covered with non-slip material have a 90 centimetre (36 inch) banister on at least one side have a guardrail at least 105 centimetres (42 inches) For new facilities, hallways in Specialized Care Bed Homes must be connected to allow continuous movement be equipped with secure, non-slip grab bars have a physical layout designed for clients with memory disorder Page of 9

28 ENVIRONMENT AND SECURITY Exits Door Watch Systems can be used in adult residential facilities where residents have a history of wandering. Helpful Information The door watch system monitors exits or doorways in the residential facility. The door watch system usually has a door strip monitor alarm and a wristband for the resident. When a resident wearing a wristband tries to leave, the door strip alarms will react audibly and visually. The resident who requires a wristband must agree to wear it. If the resident has been deemed incompetent, either his or her legal representative must agree for this system to be used. Operators of adult residential facilities are responsible for the cost of Door Watch Systems. Exits must be unobstructed and easy to open at all times. 4.6 Recreation/Common Living Area Residents must not be restricted to bedrooms. There must be a separate area for indoor recreation that provide at least thirty (30) square feet per resident common living area that is fully furnished, for example, comfortable chairs, sofas, television The courtyard attached to a Specialized Care Bed Home must be accessible and fenced-in. 4.7 Renovations For facility modifications that alter the space used to provide care services, operators must obtain prior approval from the Coordinator. 4.8 Heating Operators must maintain all rooms at a temperature in the range of Page of 9

29 ENVIRONMENT AND SECURITY 4 21 degrees Celsius (70 degrees Fahrenheit) between 07:00 am and 11:00 pm, except for special requests by residents 18 degrees Celsius (64 degrees Fahrenheit) during the remaining hours of each day, except for special requests by residents As well, operators must not use portable heating units have exterior doors and windows that fit and have tightly sealed frames to prevent drafts keep the relative humidity a minimum of forty percent (40%) and a maximum of sixty percent (60%) 4.9 Sprinkler System The Office of the Fire Marshal determines the requirements for sprinkler systems in special care homes and community residences. There must be sprinkler systems when new special care homes or community residences with four or more beds open number of residents increase residents become non-ambulatory and are not transferred out of the facility substantial renovations are made to the home or an extension is built 4.10 Fire Prevention To ensure fire standards are met, operators must have annual inspections by the Fire Marshal for facilities of four (4) or more beds. The Adult Residential Facility Coordinator may request an inspection at any time instruct residents of the evacuation procedure on admission post a written plan of evacuation in a conspicuous place have monthly fire drills in all facilities record the date of each fire drill install smoke alarms in accordance with the recommendations of the Fire Marshal and test the alarms monthly place fire extinguishers in accordance with the recommendations of the Fire Marshal use kerosene heaters only in an emergency, for example, a power outage. Operate these heaters in accordance with the instructions from the manufacturer enclose the furnace in accordance with the recommendations of the Fire Marshal Page of 9

30 ENVIRONMENT AND SECURITY 4 when using a basement area keep the heating system and the chimney clean and safe. Clean the chimney a minimum of once a year when using wood heat ensure that all locks on all outside doors and windows are acceptable to the Fire Marshal maintain a record of all written corrective orders issued by the Fire Inspectors and of the actions taken as a result of these orders Fire Safety Requirements where Residents are Non-ambulatory Special Care Homes Special Care homes must where the home is new and has four (4) or more beds, be equipped with a sprinkler system admit only residents who have Level 1 or Level 2 care needs and who are ambulatory at the time of admission where residents become non-ambulatory following admission be equipped with a sprinkler system that has a thirty (30) minute water supply. The facility must have adequate staff available to evacuate all residents in an emergency in existing facilities that accommodate non-ambulatory residents, the operator has the option of installing a sprinkler system with a thirty (30) minute water supply or relocating the non-ambulatory residents where facilities that have two (2) or more non-ambulatory residents, the Fire Marshal may conduct an Evacuation Capability exercise for all on-duty staff and residents where a home is classified as Impractical, either relocate the non-ambulatory residents or increase the number of staff to bring the Evacuation Capability up to at least a minimum Slow evacuation time where non-ambulatory residents leave a facility, accept only ambulatory residents assessed as requiring Level 1 or 2 of care Community Residences and Specialized Care Bed Homes Community Residences and Specialized Care Bed Homes must where the facility is new and has four (4) or more beds, be equipped with a sprinkler system if there are non-ambulatory residents, be equipped with a sprinkler system that has a thirty (30) minute water supply be aware that the Fire Marshal may conduct an Evacuation capability exercise for all on-duty staff and residents where facilities are classified as Impractical, either relocate the non-ambulatory residents or increase the number of staff to bring the Evacuation Capability up to Page of 9

31 ENVIRONMENT AND SECURITY 4 at least a minimum Slow evacuation time Evacuation Capabilities Helpful Information Prompt Slow Impractical Three (3) minutes or less Over three (3) minutes but not exceeding thirteen (13) minutes More than thirteen (13) minutes Operators must ensure that residents who are non-ambulatory, or require assistance with walking, are accommodated on the ground floor only General Health Standards General Health Standards must conform to any specifications and orders from the District Medical Health Officer or designate. General requirements include sanitation, lighting, ventilation, and the general health standards approved by the Department of Health. The District Medical Health Office must conduct an annual inspection of facilities of three or more beds. The Coordinator may request an inspection at any time. To ensure the general health standards, operators must use Universal Safety Precautions at all times to protect staff and residents provide supplies related to Universal Safety Precautions, i.e. gloves, etc. keep the facility free of insects and rodents take soiled linen to laundry in an enclosed container. Do not handle laundry in food preparation or storage areas store garbage separate from food handling and living areas. Remove garbage daily inoculate pets annually. Pets must be free of fleas and diseases equip with a hot water heater that meets the needs of all residents. The temperature of domestic hot water in an adult residential facility must be regulated at 120 o F ventilate with open windows or with an air exchange system forbid smoking in a Special Care Home or a Community Residence, unless there is a designated smoking room provide proper ashtrays in designated smoking rooms. These rooms must be Page of 9

32 ENVIRONMENT AND SECURITY 4 separate from all other rooms prominently display no smoking signs. Where smoking is permitted, display signs in accordance with s 4 and 5 of the Smoke Free Places Act take steps to minimize the exposure to smoke where smoking is permitted under the Smoke Free Places Act lock hazardous or poisonous substances in a cabinet or in containers store firearms in accordance with the Firearms Control Law have approval from the Coordinator to permit concentrators and liquid oxygen systems in residential facilities. Refer to Appendix D. must maintain a record of all written corrective orders issued by Public Health Inspectors and of the actions taken as a result of these orders 4.13 First Aid Operators must provide and maintain first aid providers and first aid kits at a place of employment in accordance with schedule A of Regulation of the First Aid Regulation Occupational Health and Safety Act Operators must maintain a readily accessible first aid kit in accordance with the designated authorities, that is, Red Cross, Saint John Ambulance Installation of Lifts and Elevators in Adult Residential Facilities All lifts and elevators installed in Adult Residential Facilities must be manufactured and installed in accordance with CSA Standard B Lifts for Persons with Physical Disabilities. The Department of Public Safety administers the Elevator and Lifts Act and related standards. Before installing new lifts and elevators, a licensed elevator contractor must forward drawings and specifications, in accordance with Public Safety requirements, to the Chief Elevator Inspector for registration and review. Once installed, a Department of Public Safety Inspector will inspect the lifts and elevators issue a permit on satisfactory completion of the inspection follow up with annual inspections 4.15 Emergency Preparedness In case of disaster, all Adult Residential Facilities must have a written emergency plan that looks at specific situations, for example, fire, power outages, heat, water, pandemic influenza an evacuation plan that identifies a place to go, if necessary Page of 9

33 ENVIRONMENT AND SECURITY 4 a procedure for notifying Social Development if a home has to evacuate. The plan must specify the location of each resident The plan must be reviewed annually Page of 9

34 RESIDENT CARE Client Profile and Service Types Special Care Home Client with Level 1 Care Needs Clients who are generally mobile but require the availability of supervision/ assistance on a twenty-four (24) hour basis. They need assistance and/or supervision to prepare for or complete their personal care and instrumental activities of daily living. Clients may require some professional care/supervision which can be provided through office visits, clinics or home visits. Client with Level 2 Care Needs Clients who may require some assistance or supervision with mobility. They require more individualised assistance/supervision with personal care and activities of daily living. Clients participate but require prompting, guidance and/or assistance throughout the activity. They may require professional care but it can be provided through office visits, clinics or home visits. Services A care/service provider must be present on a twenty (24) hour basis for the provision of supervision, assistance and performance of personal care, activities of daily living and/or instrumental activities of daily living. Provision and/or access to age and skill related activities are required. Interventions may require some complexity in skills and knowledge concerning personal care, skill development and behaviour management. Interventions will recognize deterioration in physical and mental health and behaviour and provide appropriate responses in various situations Community Residences Client with Level 3 Care Needs Clients who have a medically stable physical or mental health condition or functional limitation and who require supervision/care on a twenty-four (24) hour basis. The client may participate in personal care or activities of daily living but requires prompting, guidance, and assistance throughout the activity or someone else to perform the activity. The client may require supplementary professional health care/supervision at times. Page of 17

35 RESIDENT CARE 5 Services Presence of a care/service provider on a twenty-four (24) basis. Supervision, assistance and performance of personal care, activities of daily living and health related activities. Professional care/supervision related to physical/mental health condition may be required periodically. Supplementary professional care/supervision may be required at times and be provided on-site or elsewhere including a hospital, mental health centre. Provision and/or access to activities appropriate for age and skill level. Interventions require specialized knowledge and skills; the use of specialized equipment may be necessary. Client with Level 4 Care Needs Clients who have a medically stable physical or mental health condition but where difficulties with cognition and/or behaviour require supervision/care on a twenty-four (24) hour basis. Clients may display aggressive behaviour toward self and/or others. Clients may participate in personal care, activities of daily living and health related activities but could require maximum assistance and/or someone else to perform the activity. The client may require supplementary professional health care/supervision at times. An environment that will ensure the clients' safety is essential. Services Presence of a care\service provider on a twenty-four (24) hour basis. Prompting, guidance, assistance and performance of personal care, activities of daily living and health related activities. Professional care/supervision related to physical/mental health condition may be required periodically. Supplementary professional care/supervision may be required at times and be provided on-site or elsewhere including a hospital, mental health centre. Provision and/or access to activities related to age and cognitive or behavioural skills. Interventions require specialized knowledge and skills: the use of specialized equipment may be necessary. Page of 17

36 RESIDENT CARE Specialized Care Bed Homes Specialized Care Needs Clients who have a diagnosis of dementia who require Level 3 Care and require assistance with all Activities of Daily Living (ADL and IADL), but have no complex medical needs requiring on-going nursing care/supervision. These clients have a medically stable physical or mental health condition or functional limitation and require supervision/care on a 24 hour basis. The client may participate in personal care activities of daily living but requires prompting, guidance, and assistance throughout the activity or someone else to perform the activity. The client may display significant wandering behaviours and sundowning symptoms. Services Presence of a care/service provider on a twenty-four (24) basis. Supervision, assistance and performance of personal care, activities of daily living and health related activities. Professional care/supervision related to physical/mental health condition may be required periodically. Supplementary professional care/supervision may be required at times and be provided on-site or elsewhere including a hospital, or a mental health centre. Provision and/or access to activities appropriate for age and skill level. Interventions require specialized knowledge and skills as it relates to dementia and Alzheimers Disease. The facilities are equipped with safety features specific to the needs of persons with dementia. 5.2 Admission To receive services in an Adult Residential Facility, a person must apply to Social Development complete a Long Term Care Assessment prior to admission meet the eligibility criteria of the Long Term Care Program be able to pay for the residential service or qualify for a subsidy under the Standard Family Contribution Policy Admission to facilities providing specialized care beds is limited to clients assessed as requiring level 3 care services, but not requiring ongoing nursing care/supervision. The client Page of 17

37 RESIDENT CARE 5 has been assessed and approved as requiring a placement in a specialized care bed according to the Long Term Care Assessment process does not require continuous assessment, care planning and evaluation of outcomes is not bedridden, is ambulatory and medically stable has a diagnosis of dementia requiring assistance with all aspects of daily life (ADL and IADL), but does not have complex medical needs requiring on-going nursing care/supervision Residents whose condition has changed significantly since his/her admission may be reassessed. Private Pay Residents in Special Care Homes Private-pay residents may choose to be admitted in an approved special care home without a full LTC assessment. They must provide the operator with a certificate by a qualified physician as evidence of medical examination prior to admission evidence of an examination or a written social assessment indicating that the private-pay resident has social and personal needs that can be met in a special care home The examination or the written social assessment must be completed by a health care professional from Mental Health Services, the Extra-Mural Program, or Social Development, and indicate that the client is an adult who require care and/or supervision services for more than three months is medically stable does not require regular nursing care Where a special care home intends to admit a person under these conditions, the operator shall advise the Adult Residential Facility Coordinator at least ten working days before the proposed date of admission to the facility and provide the Adult Residential Facility Coordinator with a copy of the medical certificate of the person a copy of the examination or social assessment Where a person is admitted to a special care home under these conditions, the operator shall advise the Adult Residential Facility Coordinator immediately of the person s admission Page of 17

38 RESIDENT CARE 5 Residents admitted under these conditions must remain private-pay for at least 12 months. For the form used in relation to the admission of private-pay residents, pleasesee Appendix E. Special Admission Policy for Specialized Care Bed Homes Private pay residents who have not been assessed as requiring a specialized care bed home and who do not have a diagnosis of dementia may exceptionally be admitted into a specialized care bed home under the following conditions: 1. The specialized care bed home operator has a vacant bed and there are no seniors assessed at a level 3B, waiting for placement in a specialized care bed home and wanting to reside in this specific home. 2. The senior has been assessed through the LTC assessment process as requiring level 3 (high) care but is ambulatory and does not require access to daily, on-going nursing care. This assessment must be completed prior to admission. The recommendation from the supervisor using the Placement Summary Form is submitted along with the Physical Examination and History form and the Long Term Care Generic Assessment to the Regional Program Delivery Manager for decision. 3. The senior provides Social Development with a certificate by a qualified physician as evidence of medical examination prior to admission (section 22(2) of Regulation under the Family Services Act). 4. The senior is responsible for the entire cost of the placement, including any surcharge implemented by the operator, for as long as the senior resides in the home. 5. Both the senior or their legal representative and the operator have signed a waiver stating their understanding that the admission is in accordance with Social Development s Special Admission Policy. A copy of the waiver must be kept in the Social Development client file. Seniors admitted into specialized care bed homes under this Special Admission Policy must be registered in NBFamilies. 5.3 Individualized Service Plan At least annually, operators must develop, implement, evaluate and review an individual service plan for each resident. As well, operators must maximize resident Page of 17

39 RESIDENT CARE 5 funding for this purpose, for example, Day Programs, recreational activities. Helpful Information Social Development assigns a Case Manager to each person referred to a Residential Facility. The Case Manager works with the client, the operator and significant others to develop an individual service plan. The operator is responsible for implementing the plan. The amount of case management depends on the level of functioning of clients and their needs. 5.4 Elements of Programming A program is a plan of action and interventions that is developed and modified at frequent intervals with the participation of all those involved with the client, for example, the residents, families, advocates, and various professionals. Operators must develop programs that help the residents attain and maintain an optimal personal level of functioning, self-care and independence. As well, programs must recognise that each individual is unique provide individual and group activities that meet the social and recreational interests, abilities and needs of each resident develop programs that promote individual decision making, choice, inclusion and participation within the community Development of programs for an individual or a group may be related to Condition Maintenance Social/ Recreational Refers to daily interventions that focus on specific challenges facing clients, for example, incontinence, aphasia, behaviour problems, mobility problems, and feeding problems. Refers to daily interventions that help maintain the physical, mental and emotional well being of individuals. Activities may include personal care, exercise programs or other activity as stated in the case plan. Residents must be involved in social and recreational activities that meet their needs and desires, for example, special community events, outings and indoor/outdoor activities. Community/family involvement must be part of the service delivery model. The staff must use community services for the benefit of the residents. Developmental/ The focus must be on skills development, for example, Activities Page of 17

40 RESIDENT CARE 5 Productive of Daily Living and Instrumental Activities of Daily Living. As well, focus must be on participation in meaningful and age appropriate activities in either outdoor or indoor facilities, for example, literacy training, attending a day program, learning to use the transit system, and community awareness programs. 5.5 Behaviour Management Operators of Adult Residential Facilities must ensure that physical holding is used only as necessary to prevent the resident from self-injury react in self defence protect a third person Operators and employees must not utilize negative or degrading forms of corrective actions. Helpful Information Negative and degrading forms of corrective actions include, but are not limited to punishing residents physically depriving residents of basic needs, for example, food and shelter depriving residents of family visits placing residents in a locked room abusing residents emotionally 5.6 Use of Restraining Device Operators must not use restraining devices. 5.7 Staff Ratios In special care homes providing services to clients with Level 1 and Level 2 care needs, refer to Appendix J: Staff Ratio. PLEASE NOTE: Daytime ratios are to be respected for sixteen (16) hours of the total twenty-four (24) hour period and night ratios are for the remaining eight (8) hours of the twenty-four (24) hour period. Page of 17

41 RESIDENT CARE 5 In community residences providing services to clients with Level 3 care needs, refer to Appendix J: Staff ratios in adult residential facilities with Level 3 residents. PLEASE NOTE: Daytime ratios are to be respected for sixteen (16) hours of the total twenty-four (24) hour period and night ratios are for the remaining eight (8) hours of the twenty-four (24) hour period. In community residences providing services to clients with Level 4 care needs, refer to Appendix J: Staff ratios in adult residential facilities with Level 4 residents. PLEASE NOTE: Daytime ratios are to be respected for sixteen (16) hours of the total twenty-four (24) hour period and night ratios are for the remaining eight (8) hours of the twenty-four (24) hour period. In facilities providing specialized care beds, refer to Appendix J: Staff ratios in adult residential facilities with Level 3 residents. PLEASE NOTE: Daytime ratios are to be respected for sixteen (16) hours of the total twenty-four (24) hour period and night ratios are for the remaining eight (8) hours of the twenty-four (24) hour period. In community residences providing services to clients with a mix of Level 3 and Level 4 residents The staffing ratios for a facility with grandfathered and/or Level 3 residents will apply if the number of Level 4 residents represents less than 50% of the total number of residents The staffing ratios for a facility with grandfathered and/or Level 4 residents will apply if the number of Level 4 residents represents 50% or more of the total number of residents These minimum staffing ratios must be respected. Depending on need, operators of Adult Residential Facilities have some flexibility in allocating staff during the daytime hours. For example staff may have to take a resident to the doctor or attend to other important needs of the resident the operator may choose to assign more staff during peak activity periods of the day (e.g. meal time) the operator may choose to assign more staff for a special activity during the week (e.g. group outing on a Saturday) Page of 17

42 RESIDENT CARE 5 If an Operator wants to apply for a variance to the night staff ratio, they must submit a written request to the Adult Residential Facility Coordinator that demonstrates their ability to implement an evacuation plan in accordance with the specifications of the Office of Fire Marshal. As well the submission must demonstrate their ability to meet the needs of the residents during the night shift. Upon the recommendation of the Adult Residential Facility Coordinator, in consultation with the Supervisor, and the approval of the Program Manager, permission may be given to vary the staff ratio during the (8) eight hours of the night. To vary the staff ratio in a special care home, the Coordinators may consider various factors including the condition of the residents (mobility, behaviours, etc.), the monitoring system used, sprinkler system in place, person on call, staff making rounds, layout of the facility and size of the facility. Operators granted variation to staff ratios must have the approval evaluated yearly at inspection time Cooks and housekeeping may be included in the staff ratio if they are on site and provide a service to the client, for example, preparing food, cleaning rooms. Other staff must not be included in the staff ratio, for example, accountants, secretaries. In special care homes providing services to ten (10) or less residents with level 1 and level 2 care needs, operators acting as staff members may be authorized by the Adult Residential Facilities Coordinators to sleep during the night. However, operators must demonstrate that at night the needs of the residents are met. Helpful Information To allow operators to sleep during the night, the Adult Residential Facility Coordinators consider the monitoring system used, the staff making rounds and clients with dementia. In larger facilities providing services to level 1 and level 2 care needs, staff must be awake during the night. In community residences providing services to residents with level 3 and level 4 care needs, staff must be awake during the night. Page of 17

43 RESIDENT CARE Nutrition Services Operators must give the residents the opportunity to help in the planning and the preparation of meals and snacks. Encourage residents to utilize kitchen facilities to prepare and or access their own snacks make meals available to clients in accordance with Canada's Food Guide to Healthy Eating, or in accordance with a diet as prescribed by a doctor or a dietician post a monthly menu for the residents provide a pleasant setting for meals provide supper and breakfast within fifteen (15) hours of each other, not counting of evening snacks establish the following recognized meals 07:00 am - 09:00 am Breakfast 11:30 am - 01:30 pm Lunch 05:00 pm - 07:00 pm Dinner make exceptions when residents are not present for meals give nutritious snacks between meals and in the evenings at no additional cost to the client prepare enough food at each meal to allow for reasonable servings Helpful Information Seek assistance with menus from a nutritionist or other qualified professionals, if necessary. Refer to Appendix F for information on menu planning, eating problems and the nutritional care of residents with special problems. 5.9 Personal Care Staff in adult residential facilities assists residents with their needs as related to personal care, self-sufficiency and cognitive functioning. Professional nursing and rehabilitation care can only be provided by nurses or rehab professionals. Page of 17

44 RESIDENT CARE 5 Helpful Information Nursing and rehabilitation functions in a residential facility can only be performed by nurses and rehabilitation professionals. Delegation refers to the assignment of a specific task or activity, by an extra mural program (EMP) service provider, to another individual. Delegation is carried out on an individual client basis. Under certain conditions a staff member in a residential facility may provide these services when the following conditions have been met: The operator must approve the designation of a specific function to a specific staff member The professional delegates the function to the specific worker agreed upon by the operator The delegating professional trains the specific worker to perform the delegated function The delegating professional provides regular supervision of the specific worker in performing the delegated function The delegated function is not transferable but is client-specific Encourage residents to bath or shower and shampoo their hair every other day, or at least twice a week. Follow the procedures in accordance with in Appendix G when providing foot care to residents. Refer specialized foot care to professionals Do Not Resuscitate Order In situations where there is a Do Not Resuscitate (DNR) order on file for a client, the operator must deliver the DNR order to the Emergency Measure Services when they arrive. The operator could consult a lawyer to determine whether or not to follow the advance directive Medical Consent Operators of Adult Residential Facilities do not have the authority to give consent on behalf of a resident for medical intervention or to sign DNR orders. Page of 17

45 RESIDENT CARE 5 Helpful Information If it is a medical emergency, under the Hospital Act, the physician can provide medical treatment without consent. Legal authority to make decisions for another person can also be granted as follows: 1. power of attorney (enduring) status, 2. appointment as committee of a person under the Infirm Persons Act, or 3. treatment order (section 39 (1) d, Family Services Act) 5.12 Hospital Transfers Operator s must ensure relevant information accompanies all residents sent to hospital. See Appendix I as an example where possible ensure resident is accompanied by another individual; example, staff, family member, friend notify next of kin or legal representative of the transfer 5.13 Administration of Medication Operator s Responsibility Operators are responsible for establishing and maintaining policies and procedures that are suitable for the specific needs and circumstances of residents. The policies must address the following: Quality control system providing for safe, secure methods of acquiring and storing medications The operator must ensure that: - prescribed and over-the-counter medication is not in the resident s possession or in the resident s room, unless authorized by the ARF Coordinator with the following conditions: 1) physician provides written authorization 2) safety of the other residents is not jeopardized, e.g. medication is kept in locked drawer/container in resident s room - medication is stored in locked cabinets. Access to drug cabinets is limited to authorized staff. - details of each prescription are recorded on the Medication Record Form for each resident or on the MAR sheet. Page of 17

46 RESIDENT CARE 5 - the medicatio cart is under the supervision of a designated staff member at all times or kept in a locked room when not in use. - a copy of the physician s current order or copy of each prescription is in the resident s file - unused, discontinued or expired medication is stored safely and separately from other medications and brought to the pharmacy for safe disposal at least once a month. Administration and Recording of Medication - The resident, or the person with legal authority to represent the resident, must provide written consent/authorisation for the facility to administer medication by using the form Medication Record supplied by SD or by using a similar form. - Only direct care staff who have been authorized and trained by the operator may administer medication. - Authorized staff must: o positively identify residents prior to administering medication and treatment o check client identity on the medication container label prior to administering medication o check direction on medication container carefully, paying particular attention to special circumstances o ensure the correct medication is administered as prescribed: in the correct amount, to the right resident, at the right time o administer medication from the original pharmacy dispensed container with affixed pharmacy label stating residents name, medication name and directions for administration o show another staff member the measured dose before administering insulin to the resident o administer oral and topical prescription medication in accordance with a physician s direction o any changes to a prescribed medication must be accompanied by a written order o administer over-the-counter medication in accordance with the advice of a physician, a pharmacist, a nurse or other medical professionals to ensure there is no negative interaction between prescribed medication and over-the-counter medication. o monitor residents conditions and document any changes in residents files o record all blood sugar levels, blood pressure and/or other vitals in the resident s file, when applicable o ensure that the pharmacy-prepared medication administration record (MAR) for all medication prepared for the resident includes Page of 17

47 RESIDENT CARE 5 the date, time, dose, and route, where applicable. The record must be initialled by the authorized staff who prepares and administers the medication immediately following administration, and before administering medication to another resident o document on the pharmacy-prepared administration record (MAR) when a medication is not administered (refused, absent, hospital etc). - Staff may assist residents to self-medicate through such means as removing caps or covers, passing a container to the individual, or helping to assemble equipment. If a resident is given the wrong medication, staff must immediately contact the pharmacy or a doctor to seek advice and instruction on the measures to be undertaken. Instructions provided by the pharmacist or doctor must be recorded in the resident s file. Staff must also notify the operator/supervisor, and the family. An incident report must be sent to the SD. Training Operators must ensure that personnel authorized to administer medications receive adequate preparation regarding the scope and limitations of their responsibilities to safely assume this function Communicable Disease To handle communicable diseases isolate residents suspected of having a communicable disease have a physician examine the resident and give instructions to protect the other residents Helpful Information Operators with Internet access are encouraged to consult the NB Government web site at: for further information on communicable diseases. Blood borne infections refer to HIV, Hepatitis B and Hepatitis C. Refer to Policies and Procedures respecting HIV/AIDS, Hepatitis B and Hepatitis C Infections. Page of 17

48 RESIDENT CARE Special Services Operators must coordinate the provision of specialized health care services for all residents in accordance with their needs encourage residents to have annual medical, dental and, where warranted, eye and hearing examinations file a written record in the facility of all medical visits, consultations and treatments to residents Residents suffering from certain conditions should wear a Medic Alert Bracelet. Examples of these conditions are diabetes, epilepsy and drug allergies Money Management Residents receiving financial assistance from Social Development must retain the designated amount as a personal comfort and clothing allowance. Comfort and Clothing Allowance Rates Helpful Information April $ April $ Helpful Information Residents may use the comfort and clothing allowance to cover expenses associated with : clothing/personal items co-pay for prescription drugs additional fees for eye glasses, dentures and hearing aids transportation not covered by other programs Operators and employees should not accept gifts or money from the residents or their families. Operators who are also trustees must record expenditures, made on behalf of residents, on the Financial Record Form # (5/08). Page of 17

49 RESIDENT CARE 5 Agreements of trustee forms, see appendix H, will be used for the following situations where residents cannot manage their comfort and clothing allowance and there is no family member or other representatives willing and/or able to do so residents cannot manage their income (e.g. OAS/GIS, CPP, etc.) and there is no family member or other representatives willing and/or able to do so When receiving monies or other valuable securities for the benefit and use of residents, operators must deposit valuables or monies in a safe place and keep a record issue receipts and keep copies of all receipts record disbursements to or for the residents at the request of the residents, release part or all of those monies or securities to the residents not pool the Comfort and Clothing Allowance of residents allow residents to manage money for personal use in accordance with their competencies supply soap, shampoo, toothpaste and other toiletries to the residents. However, residents who prefer special brands must make those purchases with their comfort and clothing allowance On the death of clients, any accumulation of Comfort and Clothing monies belongs to the estate of the clients. Where the deceased has relatives known to the home, operators must write a cheque to the estate of the deceased for the accumulated Comfort and Clothing Allowance. Send this cheque to the next of kin Clothing Operators must ensure that residents have supply of clean personal clothing, consistent with size, age and season ownership of clothes purchased by or for them. On leaving the facility, residents take their clothing with them opportunity to select/purchase their own clothes in accordance with their abilities 5.18 Resident Records For all residents, operators must maintain a personal file. The file should include, but not be restricted to Individual service plan Page of 17

50 RESIDENT CARE 5 Application for admission Resident Medical Long Term Care Assessment Financial Record Personal Record of Resident Medication Records Special Approvals, for example, oxygen, insulin injections, hospital beds As well, operators must collect, record and evaluate relevant data refer all persons requesting information to the Case Manager who is responsible for responding to the requests restrict access to all files or records pertaining to residents to authorized personnel, the resident, the Adult Residential Facility Coordinator, case manager and those authorized in writing by the Case Manager retain the files of clients who left the residential services permanently. Maintain the files in a secure place. After five years, purge the files in a manner that protects client confidentiality Operators should emphasize participation in community for all residents in accordance with their abilities. This participation is an integral component of the program. A caring environment includes the following elements access to information and resources opportunities to develop personal and meaningful relationships and networks respect and protection of personal privacy and personal space choice to participate in activities consistent with their age opportunities to make decisions availability of cherished possessions within reach Page of 17

51 SOCIAL ENVIRONMENT Orientation upon Arrival and Departure To welcome, all prospective residents, operators must recognize their fears, anxieties, and questions give a tour of the facility introduce the staff and other residents discuss the rules and expectations inform them about the activities expected in group living inform them about the process for hearing concerns of residents encourage all residents to create a home like environment inform them of the social and recreational resources, and community based programs To prepare residents for leaving, operators must help them work through separation from staff and other residents at the facility adopt a positive or optimistic outlook toward their new placement understand possible regressive behaviour that they may experience because of anxiety brought on by the move 6.2 Resident Rights The Human Rights Act prohibits both direct and indirect discrimination. Operators must uphold the provisions of the Charter of Rights and Freedoms, the Occupational Health and Safety Act, the Health Act and the Human Rights Act. In accordance with Regulation under the Family Services Act, operators must operate the facility in a manner that will maintain the spirit, dignity and individuality of the residents. Operators should ensure that 1. Every Resident is treated with courtesy and respect and in a way that fully recognizes the resident's dignity and individuality and is free from mental and physical abuse. 2. Every Resident is properly sheltered, fed clothed, groomed and cared for in a manner consistent with his or her needs of 3

52 SOCIAL ENVIRONMENT 6 3. Every Resident is told who is responsible for and who is providing the resident's direct care. 4. Every Resident is afforded privacy in treatment and in caring for his or her personal needs. 5. Every Resident is allowed to keep in his or her room and display personal possessions, pictures and furnishings in keeping with safety requirements. 6. Every Resident o o o o is informed of his or her medical condition, treatment and proposed course of treatment; who is able to do so has the opportunity to give or refuse consent to treatment, including medication, in accordance with the law and to be informed of the consequences of giving or refusing consent; has the opportunity to participate fully in making any decision and obtaining an independent medical opinion concerning any aspect of his or her care including any decision concerning his or her admission, discharge or transfer to or from a home; and has his or her medical records kept confidential in accordance with the law. 7. Every Resident is allowed to designate a person to receive information concerning any transfer or emergency hospitalization of the resident and where a person is so designated to have that person so informed forthwith. 8. Every Resident is allowed to exercise the rights of a citizen and raise concerns or recommend changes in policies, and services on behalf of himself or herself or others to the Facilities Staff, Government Officials or any other person inside or outside the home, without fear of interference, coercion, discrimination or reprisal. 9. Every Resident is allowed to form friendships and enjoy them. 10. Every Resident is allowed to meet privately with his or her spouse in a room that assures privacy and where both spouses are residents in the same home, they are allowed to share a room according to their wishes, if any appropriate room is available of 3

53 SOCIAL ENVIRONMENT Every Resident is allowed to pursue social, cultural, religious and other interests, develop his/her potential and is given reasonable provisions by the home to accommodate these pursuits. 12. Every Resident is informed in writing of any law, rule or policy affecting the operation of the home and of the procedures for initiating complaints. 13. Every Resident manages his/her own financial affairs where the resident is able to do so. 14. Every Resident lives in a safe and clean environment. 15. Every Resident has access to protected areas outside the home in order to enjoy outdoor activity, unless the physical setting makes this impossible. 16. Every Resident has the right to confidentiality of information about them. 17. Every resident can contact their case manager, if requested. 18 Every Resident can access the mail delivery system and assurance that mail cannot be opened without the consent of residents. 19. Every resident can access a telephone that is located where the residents have privacy while talking on the phone. 20. Every resident can have visits and involvement of family members of 3

54 APPENDICES 7 Appendix A: Forms Application Form for an Operator of an Adult Residential Facility (04/08)...2 Reference Form (5/08)...6 Resident Medical Report (6/08) Incident Report (5/08) Report of Death (5/08) Financial Record (5/08) Personal Record of Resident (5/08) Medication Record (5/08) of 36

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70 APPENDICES 7 Appendix B: Oath of Confidentiality Adult Residential Facility Établissement résidentiels pour adultes OATH OF CONFIDENTIALITY I,, an employee of, Province of New Brunswick, do certify: SERMENT DE DISCRÉTION Je,, étant embauché par, dans la Province du Nouveau-Brunswick, atteste: THAT I understand that all persons who are receiving care services from, have the right to confidentiality and that I, as an employee, have the responsibility to preserve and respect that right; Que je comprends que toute personne qui reçoit des soins de, a droit à la confidentialité et que j'ai, comme employé(e), l'obligation de préserver et respecter ce droit. THAT I will abstain from divulging the information obtained during my employment and the information which is contained in the resident records. Que je m abstiens de divulguer l'information qui me sera donnée au cours de mon emploi et celle contenue dans les dossiers de chaque résident. Signed before me this day of, 20 in the city of, New Brunswick. Signé devant moi ce jour de, 20, dans la ville de, Province du Nouveau Brunswick. Facility Operator or Designated person Opérateur de l établissement ou Personne désignée 20 Employee Employé(e) of 36

71 APPENDICES 7 Appendix C: Plan Review Technical Inspection Services Services d inspection technique 495A Prospect Street, Fredericton, NB E3B 9M (tel) (fax) ADULT RESIDENTIAL FACILITIES (Special Care Homes and Community Residences) If you intend to open a new adult residential facility or perform major renovations or increase the number of residents in an existing adult residential facility, you must first submit detailed drawings to the Adult Residential Facility (ARF) Coordinator with the Department of Social Development who will then forward the package to Technical Inspection Services for the Fire Plan review required by the Fire Prevention Act. Please submit all information to the ARF coordinator as 1 package. The written response will be mailed, ed or faxed to you and copies sent to the ARF coordinator, the Regional Fire Inspector / Fire Department and building owner. Written response will be sent approximately 3 weeks after all required information has been submitted to Technical Inspection Services. A fee is effective as of April 1, 2009 for Fire Plan review and you will be directly billed by Technical Inspection Services. Your submission to Social Development must include 1) the civic address of the property, 2) a site plan showing a new building or a new addition plus existing building as it will be located upon the property, 3) scaled or fully dimensioned floor plans of EACH complete level of the building (including any existing sections) including exits, partitions, windows, doors, stairs, room identification (i.e. kitchen, storage, etc.), type of heating, wood / gas stoves, fire alarm components, fire extinguishers, emergency lighting, etc., 4) for a new building or an addition provide exterior building elevations for existing buildings provide a colour photo of each exterior face of the building, 5) construction details such as wall, floor and roof assemblies, fire separations, fire doors, etc. All residents must be ambulatory, able to recognise and respond to a fire alarm signal and be capable of exiting the building with minimal assistance. Elevators may not be used to evacuate the building. Exit doors must open directly to the exterior. Exit and egress doors must be readily operable for egress at all times without the use of keys, special knowledge or special devices. For enclosed exit stairs, landings are required at the top and bottom of the stair. Windows and balconies are not considered as exits. Residents may not be locked into a room or into the building. The entire building will require an automatic sprinkler system conforming, as a minimum, to NFPA 13R. These building are not protect in place facilities such as nursing homes and hospitals the entire building must evacuate upon activation of the fie alarm/automatic sprinkler system If less than 10 people sleep in the building; hardwired, interconnected smoke alarms are required on each floor level and in each bedroom. The smoke alarms must be manufactured for this number of interconnections. If more than 10 people sleep in the building; an AC/DC fire alarm system conforming to the National Building Code and including smoke detectors in each bedroom, is required. The fire alarm system must be monitored by an independent supervisory station. An evacuation exercise is required for all new Community Residences of 36

72 APPENDICES 7 ADULT RESIDENTIAL FACILITIES Page 2 of 2 Civic address of the building: Tel: Fax: Name and civic address of building owner: Tel: Fax: Name and civic address of operator IF different from above: Tel: Fax: Total number of people sleeping in the building, including residents, owners, operators and staff: Please include any other information which may be useful for the fire plan review: INITIAL FIRE INSPECTION After completion of construction, renovations, etc. and prior to opening for business, your residential facility will require a site visit by the Fire Inspector to ensure appropriate fire safety requirements are in place. The name and phone number of the Fire Inspector will be included with the written response sent to you from Technical Inspection Services. The Fire Inspector will send a report to Social Development for licensing purposes. Please call the Fire Inspector several days before you wish to open for business in order to arrange for the initial scheduled fire inspection. All work should be complete prior to this inspection. If work is not complete when the Fire Inspector arrives for this initial scheduled fire inspection, a fee may be charged for any additional site visits. Operators Signature of 36

73 APPENDICES 7 Appendix D: Use of Oxygen USE OF OXYGEN GUIDELINES A facility wishing to admit a resident using an oxygen concentrator or liquid oxygen must develop appropriate policies and procedures governing its usage. It is the operator s responsibility to ensure that the unit is CSA (Canadian Standards Association) approved and that all safety requirements are met including those of the National Fire Code and the Fire Safety Standards required by the Provincial Fire Marshal s Office. Facilities permitting the use of oxygen concentrators or liquid oxygen for the treatment of residents shall ensure that applicants are aware of facility policies governing usage, prior to admission. Where applicable, policies and procedures should be approved by the board of directors. It is the financial responsibility of the resident to obtain, maintain and service the oxygen equipment; in accordance with the manufacturer s recommendations. Prior to initiation of treatment, a registered respiratory technologist or qualified representative of the supplier must visit the facility and instruct the resident and appropriate staff members in the operation and maintenance of the unit. This instructional session shall include the appropriate safety precautions to be followed. Safety precautions to be followed by residents, visitors and employees include the following. Fire Safety Precautions to be taken when Oxygen is used No smoking must always be the rule. Keep cigarettes or any burning tobacco away from the area where the equipment is being used. Keep the equipment at least 1.5 M (5 Ft) away from any electrical appliance. Keep the equipment at least 1.5 M (5 Ft) from open flames, sparks or any heating sources such as furnaces on stoves. Keep flammable materials away from the equipment. Oils and grease ignite easily and burn rapidly in the presence of concentrated oxygen. Never attempt to lubricate the oxygen equipment. Never use aerosol sprays containing combustibles near liquid oxygen systems of 36

74 APPENDICES 7 Liquid Oxygen Systems Requirements The equipment must be CSA (Canadian Standards Association) approved. Supplier must confirm that equipment meets NFPA (National Fire protection Association) 99 guidelines including the proper sections of NFPA 99 identified. The name, address, telephone number and persons name of the installer must be provided. Proof in writing that the person who fills the cylinders has been given the proper training by the installer. Also, that written instructions have been left at the home. Proof that the Fire department has been notified in writing of the installation. Additional information is required on the pressure of the liquid oxygen. Is it approximately 22 psi of 36

75 APPENDICES 7 Appendix: E Admission of private-pay residents in a special care home I understand that private-pay applicants may be admitted in an approved special care home, without a full LTC assessment, if they provide the operator with a certificate by a physician as evidence of medical examination prior to admission, and if there is evidence of an examination or a written assessment indicating that the private-pay applicant has social and personal needs that can be met in a special care home. Applicants admitted under these conditions must remain private-pay for at least 12 months. Name of Applicant of Birth Address Next of kin or Person to contact in case of emergency Name Relationship to Applicant Phone (day) (evenings, week-ends) (Signature of Applicant) I have met personally with the Applicant,. I am satisfied that he/she is an adult who require care and/or supervision services for more than three months; that he/she is medically stable, and that he/she does not require regular nursing care (if applicable, please attach any additional information to this form). I am of the opinion that the Applicant s social and personal needs can be met in a special care home. I am a health care professional from Mental Health Services, the Extra-Mural Program or Social Development. (Signature) Print your name Phone Special care home where the Applicant wants to be admitted Name of special care home Name of Operator Phone Address of special care home A copy of the medical certificate of the Applicant is attached. (Signature of special care home operator) (The special care home operator needs to fax this document to the ARF Coordinator at least 10 working days before the proposed date of admission) of 36

76 APPENDICES 7 1 MENU PLANNING Appendix F : Nutrition NUTRITION The total amounts recommended Canada's Food Guide should be eaten every day however it is not necessary for every meal to contain all four food groups. Poor appetites and small portion sizes can make it difficult to meet the total recommended quantities. Where the portion size recommended by the Food Guide is too large, it may be reduced but the number of servings per day must be increased. Menus should include a wide variety of food, be high in fibre, and low in fat, salt, and caffeine. The advantages of this type of menu are as follows: 1. A high fibre menu will reduce the residents' need for laxatives and contribute to their overall sense of well being. 2. Reducing the fat content will eliminate the need for many residents to be on more restrictive therapeutic diets such as: low cholesterol, low fat, weight reduction, soft digestive or anti-reflux diet. 3. Controlling the over all amount of salt will reduce the need for anti-hypertensive and diuretic medication, and free many residents from a more restrictive low sodium diet. 4. Limiting the number of very sweet desserts served may reduce the need for hypoglycaemic medication for "borderline" diabetics and will improve control for those with more serious diabetes. The following Guidelines should be considered in planning nutritional menus. Replace the rich, sweet desserts with high fibre breads, cookies, and muffins, fruit desserts, and milk puddings. Use 1% milk and wholewheat bread. Limit the overall use of salted meats and fish (ham, bologna, weiners, bacon, salt cod, etc.) to twice weekly. Limit the use of deep-fried foods to once a month if at all. Use whole grain cereals, or add bran to refined cereals. Use fruit juices rather than beverage crystals. Minimize soaking time prior to cooking potatoes and other vegetables Cook vegetables for a short time in a small amount of water. Steaming, baking or microwaving vegetables is preferable to cooking in water. Favour fresh or frozen vegetables. When canned vegetables must be used, save the liquids to use in soups, sauces and gravies. Serve dried peas and beans every week, as baked beans, in hearty main - dish soups and bean salads. Increase the calcium content of each day's menu by serving milk or cheese. The following guidelines should be considered when preparing meals or baking. Increase the fibre content of baked goods by substituting wholewheat flour for some or all of the regular flour, or by adding bran, dried fruits, or minced nuts. Increase the fibre content of casseroles and ground meat dishes by adding bran, oatmeal or extra vegetables of 36

77 APPENDICES 7 Bran may be added to such foods as: - cooked or dried cereals, pancakes, cookies and breads - ground meat, casseroles - crunchy dessert toppings. Reduce the fat content in soups and stews by using only lean meats, by not browning the meat or sautéing the onions at the start of the recipe, and by skimming any fat off the surface before serving. Reduce the saturated fat in many baked goods by using oils such as canola oil, safflower oil, sunflower oil, or corn oil instead of shortening or lard. The sugar content of many desserts can be reduced without other alterations to the recipe. Enhance the flavour of meals by using herbs and spices rather than adding extra salt. Snacks While snacks are not usually considered as part of the menu planning process, they are important to the well being of residents with reduced appetites, eating disabilities, and increased nutritional needs. The following snack guidelines should be considered; Plan a menu of nutritious snacks to be offered to residents at least twice a day, to meet the need of those requiring small, frequent meals, and those with larger appetites. Consider offering a "fruit of the day" for the afternoon nourishment, whole, cut-up, and pureed, to meet the texture requirements of all residents. Consider offering high protein foods nourishments, for example, cheese and crackers, egg sandwiches, yogurt, toast and peanut butter, high protein milkshakes or puddings, etc. Include a beverage with each snack. 2 PROBLEMS AFFECTING EATING Problem Nausea Suggestions Consult the physician and pharmacist about medications which may be causing nausea, and ask them about anti-nausea medication. Anti-nausea medication, if prescribed, should be taken ½ to 1 hour before mealtime. Constipation is a common cause of nausea; check under Constipation for suggestions Encourage adequate fluid intake to prevent dehydration. Generally ice water, lemonade, juices, popsicles, soft drinks, mint tea and sherbet are well tolerated. Provide small, frequent meals. The following foods are tolerated: soup, custard, pudding, ice cream, frozen yogurt, jello and canned fruit packed in juice or light syrup crackers, plain cookies, plain toast Cold meals, which have less aroma, are often better tolerated. Foods which are greasy, spicy, or too sweet may cause difficulty of 36

78 APPENDICES 7 Confusion, Poor Attention Provide a quiet eating area with minimal distractions (free from music, television, kitchen noise, etc.) Keep talk to a minimum. Assure the resident that chatting can be done after the meal. Remove unnecessary items from the table, placing one dish at a time in front of the resident. Confusion Provide assistance and simple instructions as necessary. Tell the resident what is being served. Allow sufficient time to eat. Impaired vision Always place utensils and other items in the same position on the table or tray. Put salt in a different shape shaker than pepper. Tell the resident what is being served and guide his/her hand to where each food is placed on the plate or table. Use dishes in a contrasting colour to that of the table top, or place mat. Offer dishes that are easy to use such as a scoop plate or plate guards. Trembling, poor coordination Offer nonslip matting under dishes to prevent slipping. Offer plate or plate guard. Use extra large bowls, glasses, and cups for liquids and half-fill them to reduce spilling. Offer a covered glass or cup with a sipping spout to prevent spillage. A two handled mug may be helpful. Try weighted cutlery and heavy dish-ware rather plastic ware. Try a weighted wrist cuff. Allow hot food and liquids to cool to a safe temperature before serving. Weak grasp Consult the pharmacist and physician regarding medications which may cause lethargy or increase muscle weakness. Allow hot foods and liquids to cool to a safe temperature before serving. Offer cutlery which is easy to use such as cutlery with large built up handles or cutlery with loop handles. Offer two-handled mug. Offer scoop plate or plate guard of 36

79 APPENDICES 7 Offer lightweight cutlery, mugs and glasses. Offer extra-long straw secured to cup with a straw holder to eliminate need to lift the cup. Serve small portions of beverage at one at a time. Consult the pharmacist and physician regarding medications which may cause lethargy or increase muscle weakness. Use of one hand Utensils should be placed on the resident's functional side. Offer rocker knife. Avoid use of portion-packaged foods such a margarine, milkers/creamers, jam, etc. Offer scoop plate or plate guard. Offer pre-cut texture modification. Encourage the use of finger foods. 3 CONDITIONS REQUIRING SPECIALIZED NUTRITIONAL CARE Food Allergies Allergic reactions to food may involve the skin, vomiting, diarrhoea, cramps, asthma, bronchitis, headaches, irritability, or anaphylactic shock. The severity of the reaction may range from merely being a nuisance to a risk of death. Reaction can be immediate (less than an hour after exposure), or delayed (several hours to several days after exposure). Foods which most often cause allergic reactions are: Milk and milk products, eggs, nuts, fish, seafood, wheat, citrus fruits, strawberries, and chocolate. Tartrazine, an artificial colouring widely used in foods also produces allergic reactions in some people. Persons allergic to tartrazine are also allergic to food additives sodium benzoate (a food preservative), and salicylates (e.g. mint, aspirin). General recommendations: 1. The resident must completely avoid the food to which he/she is allergic, as well as commercially or home prepared foods containing the food as an ingredient. It is important to read labels carefully. 2. If the food is an important source of nutrients (e.g. milk) a plan should be developed by a dietitian in order to prevent nutrient deficiency. 3. Clearly identify the residents with food allergies of 36

80 APPENDICES 7 If a food allergy is suspected but not identified, proceed as follows: 1. Eliminate the foods most likely to cause allergic reactions from the diet until symptoms have disappeared, up to a maximum of two weeks. (See list above). 2. If symptoms have cleared up at the end of this time, reintroduce each eliminated food, at a rate of one food every two days and watch for the recurrence of symptoms. 3. Keep a daily record of foods eaten and changes in resident's condition. 4. Reintroduced foods not causing a reaction, may remain in the diet. Those causing a reaction should be eliminated immediately. After the symptoms have disappeared, continue introducing the remaining foods, as resident may be allergic to more than one food. If symptoms did not disappear during period of elimination, or if they did not recur during period of reintroduction, then a food allergy is probably not the problem. Alzheimer's Disease The nutritional care of residents with Alzheimer's disease presents a challenge to caregivers. The skill required for eating gradually diminish due to deterioration of physical and mental ability. Uncontrolled weight loss is usually seen in the final stages, despite quality care. Other nutrition-related behaviours and changes seen in Alzheimer's include; continuous pacing, confusion at mealtimes, refusal to eat, uncontrolled eating and stealing of food, loss of perception of thirst, inability to feed self, inability to chew and swallow food. It is important to note that the unusual eating behaviours exhibited in Alzheimer's are usually temporary and should only be considered a problem if persistent or if they present an immediate danger. General recommendations: 1. Monthly weighing is often necessary. Monitor weight and notify the physician if undesired weightloss occurs in two consecutive weighing. 2. Insure adequate portion size. Residents who pace or wander continuously have much greater energy requirements than most residents. Stealing food from others at mealtimes may be a sign of inadequate serving sizes. If larger portion sizes are not eaten, provide frequent snacks. 3. If uncontrolled eating and continued weight gain are a problem notify a physician. 4. Provide adequate supervision and appropriate assistance at mealtimes. This may mean; - reducing the number of foods presented at one time - reducing portion size and offering between meal snacks. - reducing distractions such as noise, music, table ornaments, etc. - ignoring inappropriate eating behaviours if not harmful. If resident becomes aware of mistake and is upset, lead him/her away, replace the meal, and bring the resident back to the table to start over. The mistake will have been forgotten. - Serving foods pre-cut and pre-mixed, such as casseroles and stews. - Tactfully reminding the resident to eat, to chew, and to swallow as required. 5. If resident repeatedly refuses to eat, try offering frequent small meals and snacks of favourite foods, experiment with different types of foods, different eating areas, and different table companions or caregivers. And do not hesitate to request help from the family. Constipation Constipation is a serious medical problem in long term care facilities. The following recommendations may help to counteract constipation of 36

81 APPENDICES 7 1. Ensure adequate hydration of all residents. A fluid intake of 6-8 cups (1.5-2L) per day is essential to promote normal bowel function. 2. Increase the insoluble fibre content of the regular diet by; - adding natural bran to all cooked cereals - adjusting recipes to increase use of whole wheat flour - serving whole wheat bread as the standard - offering stewed prunes daily at breakfast - offering bran muffins for snacks. 3. Promote physical activity. Body movement helps bowel muscles do their work. Standing even for short periods of time helps massage the bowel. Residents in wheelchairs can pull their knees up towards their chests or lean forward to massage the bowel. Rolling the knees from side to side in bed is also effective. 4. Encourage good bowel habits by helping the resident to the toilet at the same time each day, preferably right after a meal. Respond as soon as resident requests to go to the bathroom; failure to respond to the urge is a major cause of constipation. Diarrhoea Diarrhoea may be either acute or chronic. Acute diarrhoea may be caused by viral or bacterial infections, certain drugs (e.g., broad-spectrum antibiotics, ferrous sulphate, antacids containing magnesium), or faecal impaction. Diarrhoea is considered chronic if it persists for more than two to three weeks. Chronic diarrhoea may lead to weight loss and significant nutritional deficiencies. Before dietetic treatment is undertaken, the cause of the chronic diarrhoea should be diagnosed. In cases of chronic diarrhoea, consult a physician. Recommendations for Acute Diarrhoea 1. Identify and eliminate the cause of the diarrhoea, if possible. 2. Provide a clear liquid diet for the first 24 hours. Do not continue the clear liquid diet for more than hours. If the diarrhoea persists, consult a physician. 3. Ensure adequate fluid intake,(i.e. broths and fruit juices). Beverages containing caffeine (coffee, strong tea, colas) are not recommended for residents with diarrhoea. 4. If after 24 hours the diarrhoea has subsided considerably, the following foods may be reintroduced gradually in small quantities: - cream of wheat - toasted white bread or crackers with little margarine - rice - ripe bananas - applesauce - canned peaches or pears - eggs (not fried) - lean meat,fish, or chicken (no gravy) Dairy products should be reintroduced cautiously, after the diarrhoea has disappeared altogether of 36

82 APPENDICES 7 Gas (Flatulence) Flatulence is characterized by bloating, cramping, belching and passing gas. It can sometimes be controlled with a change of diet and/or behaviour. General recommendations 1. The following foods are thought to increase gas in many individuals. The resident should be instructed to avoid only those foods which are a problem for him/her. Eating only small quantities of the problem foods usually helps. - beans (e.g. kidney beans) - bran - nuts - vegetables (especially corn, onions, broccoli, radish, cauliflower, spinach, brussels sprouts, egg-plant, cabbage). 2. Consumption of pop and beer, should be reduced. 3. If a high fibre diet is required to prevent constipation, increase fibre gradually. The gaseous effect will lessen with time. 4. The following habits, which often result in swallowing air, may cause flatulence. Their elimination may provide some relief: - Drinking through a straw - Eating rapidly - Gulping liquid - Chewing gum - Sucking on hard candies - Smoking excessively - Eating while anxious or under stress - Eating or drinking too fast and not chewing thoroughly - Slurping or talking with a full mouth - Forced belching 5. Increased physical activity can reduce discomfort associated with flatulence and facilitate the passage of gas of 36

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